Practice Economics

An increasing number of hospitalists are pursuing part-time schedules to cater to lifestyle demands and personal desires. According to a 2010 survey conducted by the American Medical Group Management Association and Cejka Search, 21% of physicians in the U.S. are working part time, compared with only 13% in 2005.

Among those part-time physicians, the fastest-growing segments are men approaching retirement and women in the early to middle stages of their careers. Senior physicians who are tired of the commitment that comes with full-time employment increasingly are opting for part-time employment as a transition into retirement. Physicians with young children are seeking part-time employment to be more active in child-rearing.

The medical community generally has welcomed the opportunity to incorporate part-time physicians into hospital settings as a way to maintain female physicians, senior physicians, and physicians in specialties experiencing shortages. Physicians who are retained on a part-time basis should be cognizant of the following areas of the physician’s employment or independent contractor agreement:

• Independent contractor or employee status;
• Compensation;
• Benefits;
• Professional liability (malpractice) insurance; and
• Restrictive covenants.

Independent Contractor vs. Employee

Oftentimes, physicians assume that just because he or she is working part time, he or she is an independent contractor. That is an inaccurate assumption. The amount of time a physician works is not the determining factor as to whether someone is an employee or an independent contractor of the practice or hospital. Whether a physician is an employee or an independent contractor is a distinction with real consequences for tax purposes and protections under federal and state labor and employment laws.

Generally, labor and employment laws provide protections for employees, but these protections do not extend to independent contractors. With regard to taxes, if a hospitalist is an employee, the employer is required to withhold income, Social Security, and Medicare taxes, and pay unemployment tax on wages paid to the hospitalist. Conversely, if a hospitalist is an independent contractor, the practice or hospital will not withhold or pay taxes on payments to the hospitalist; rather, the individual hospitalist will be responsible for making those payments to the IRS and state tax authorities. It is imperative that the contract clearly indicates whether the hospitalist is an employee or an independent contractor, as well as the corresponding responsibilities of the parties.

Compensation and Benefits

Partial compensation for part-time work is logical, but determining a fair and competitive compensation package is not always as straightforward when it comes to part-timers. There are two general models that practices and hospitals use to determine compensation for hospitalists working part time. First, the physician may be paid a percentage of a full-time physician’s salary, based on the number of hours worked. Second, the physician may receive a per diem rate or an hourly rate. As with full-time physicians, there are various ways to formulate a part-time physician’s compensation, and the method used should be explicitly outlined in the physician’s employment or independent contractor agreement.

Benefit plans and arrangements (such as health, dental, vision, retirement plan, pension plan, disability coverage, life insurance, etc.) frequently are provided to employees and infrequently provided to independent contractors. Whether a physician who is working part time will receive benefits will vary from employer to employer. A threshold issue, however, is whether a part-time worker is even eligible to receive certain benefits. Many health, dental, and vision plans require employees to work a minimum of 30 hours a week on a regular basis, thus excluding part-time employees who work fewer hours. For retirement and pension plans, employees typically must work a minimum of 1,000 hours per year to be eligible to participate. Even if a hospitalist’s employment agreement provides that the hospitalist may receive benefits from the employer, the agreement may also provide that such a provision is subject to the terms and conditions of the particular benefit plans or arrangements.

Professional Liability (Malpractice) Insurance

While some practices or hospitals pay for a part-time physician’s malpractice insurance premiums, many shift some or all of these costs to the physician. Many insurance providers offer malpractice plans for physicians practicing part time, with reduced premiums and reduced coverage.

When negotiating a compensation package, payment for malpractice insurance should be considered. A physician also must be aware of what is excluded from coverage. For example, if a physician works part time with Hospital A and part time with Hospital B, and Hospital A provides malpractice coverage for the physician, it cannot be assumed that such coverage will cover the physician’s work with Hospital B. In this case, the physician may need a separate policy for work performed through Hospital B.

Restrictive Covenants

Although a physician might only be employed on a part-time basis, the employer might nevertheless want to protect itself by including restrictive covenants (i.e. noncompetition and nonsolicitation clauses) in the physician’s employment agreement. A part-time physician must be careful that the restrictive covenants do not jeopardize their other career objectives. For example, in the example described above with the physician working part time for both Hospital A and Hospital B, a noncompetition clause in the physician’s employment agreement with Hospital A could prohibit the physician from working at another hospital, including Hospital B.

Retaining part-time hospitalists is an increasingly attractive option for physician practices and hospitals, and part-time work is an increasingly attractive option for physicians. The items described above are just a few of the provisions that are unique to the part-time physician relationship that should be reflected in the physician’s employment or independent contractor agreement.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at sharris@mcdonaldhopkins.com.

An increasing number of hospitalists are pursuing part-time schedules to cater to lifestyle demands and personal desires. According to a 2010 survey conducted by the American Medical Group Management Association and Cejka Search, 21% of physicians in the U.S. are working part time, compared with only 13% in 2005.

Among those part-time physicians, the fastest-growing segments are men approaching retirement and women in the early to middle stages of their careers. Senior physicians who are tired of the commitment that comes with full-time employment increasingly are opting for part-time employment as a transition into retirement. Physicians with young children are seeking part-time employment to be more active in child-rearing.

The medical community generally has welcomed the opportunity to incorporate part-time physicians into hospital settings as a way to maintain female physicians, senior physicians, and physicians in specialties experiencing shortages. Physicians who are retained on a part-time basis should be cognizant of the following areas of the physician’s employment or independent contractor agreement:

• Independent contractor or employee status;
• Compensation;
• Benefits;
• Professional liability (malpractice) insurance; and
• Restrictive covenants.

Independent Contractor vs. Employee

Oftentimes, physicians assume that just because he or she is working part time, he or she is an independent contractor. That is an inaccurate assumption. The amount of time a physician works is not the determining factor as to whether someone is an employee or an independent contractor of the practice or hospital. Whether a physician is an employee or an independent contractor is a distinction with real consequences for tax purposes and protections under federal and state labor and employment laws.

Generally, labor and employment laws provide protections for employees, but these protections do not extend to independent contractors. With regard to taxes, if a hospitalist is an employee, the employer is required to withhold income, Social Security, and Medicare taxes, and pay unemployment tax on wages paid to the hospitalist. Conversely, if a hospitalist is an independent contractor, the practice or hospital will not withhold or pay taxes on payments to the hospitalist; rather, the individual hospitalist will be responsible for making those payments to the IRS and state tax authorities. It is imperative that the contract clearly indicates whether the hospitalist is an employee or an independent contractor, as well as the corresponding responsibilities of the parties.

Compensation and Benefits

Partial compensation for part-time work is logical, but determining a fair and competitive compensation package is not always as straightforward when it comes to part-timers. There are two general models that practices and hospitals use to determine compensation for hospitalists working part time. First, the physician may be paid a percentage of a full-time physician’s salary, based on the number of hours worked. Second, the physician may receive a per diem rate or an hourly rate. As with full-time physicians, there are various ways to formulate a part-time physician’s compensation, and the method used should be explicitly outlined in the physician’s employment or independent contractor agreement.

Benefit plans and arrangements (such as health, dental, vision, retirement plan, pension plan, disability coverage, life insurance, etc.) frequently are provided to employees and infrequently provided to independent contractors. Whether a physician who is working part time will receive benefits will vary from employer to employer. A threshold issue, however, is whether a part-time worker is even eligible to receive certain benefits. Many health, dental, and vision plans require employees to work a minimum of 30 hours a week on a regular basis, thus excluding part-time employees who work fewer hours. For retirement and pension plans, employees typically must work a minimum of 1,000 hours per year to be eligible to participate. Even if a hospitalist’s employment agreement provides that the hospitalist may receive benefits from the employer, the agreement may also provide that such a provision is subject to the terms and conditions of the particular benefit plans or arrangements.

Professional Liability (Malpractice) Insurance

While some practices or hospitals pay for a part-time physician’s malpractice insurance premiums, many shift some or all of these costs to the physician. Many insurance providers offer malpractice plans for physicians practicing part time, with reduced premiums and reduced coverage.

When negotiating a compensation package, payment for malpractice insurance should be considered. A physician also must be aware of what is excluded from coverage. For example, if a physician works part time with Hospital A and part time with Hospital B, and Hospital A provides malpractice coverage for the physician, it cannot be assumed that such coverage will cover the physician’s work with Hospital B. In this case, the physician may need a separate policy for work performed through Hospital B.

Restrictive Covenants

Although a physician might only be employed on a part-time basis, the employer might nevertheless want to protect itself by including restrictive covenants (i.e. noncompetition and nonsolicitation clauses) in the physician’s employment agreement. A part-time physician must be careful that the restrictive covenants do not jeopardize their other career objectives. For example, in the example described above with the physician working part time for both Hospital A and Hospital B, a noncompetition clause in the physician’s employment agreement with Hospital A could prohibit the physician from working at another hospital, including Hospital B.

Retaining part-time hospitalists is an increasingly attractive option for physician practices and hospitals, and part-time work is an increasingly attractive option for physicians. The items described above are just a few of the provisions that are unique to the part-time physician relationship that should be reflected in the physician’s employment or independent contractor agreement.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at sharris@mcdonaldhopkins.com.

An increasing number of hospitalists are pursuing part-time schedules to cater to lifestyle demands and personal desires. According to a 2010 survey conducted by the American Medical Group Management Association and Cejka Search, 21% of physicians in the U.S. are working part time, compared with only 13% in 2005.

Among those part-time physicians, the fastest-growing segments are men approaching retirement and women in the early to middle stages of their careers. Senior physicians who are tired of the commitment that comes with full-time employment increasingly are opting for part-time employment as a transition into retirement. Physicians with young children are seeking part-time employment to be more active in child-rearing.

The medical community generally has welcomed the opportunity to incorporate part-time physicians into hospital settings as a way to maintain female physicians, senior physicians, and physicians in specialties experiencing shortages. Physicians who are retained on a part-time basis should be cognizant of the following areas of the physician’s employment or independent contractor agreement:

• Independent contractor or employee status;
• Compensation;
• Benefits;
• Professional liability (malpractice) insurance; and
• Restrictive covenants.

Independent Contractor vs. Employee

Oftentimes, physicians assume that just because he or she is working part time, he or she is an independent contractor. That is an inaccurate assumption. The amount of time a physician works is not the determining factor as to whether someone is an employee or an independent contractor of the practice or hospital. Whether a physician is an employee or an independent contractor is a distinction with real consequences for tax purposes and protections under federal and state labor and employment laws.

Generally, labor and employment laws provide protections for employees, but these protections do not extend to independent contractors. With regard to taxes, if a hospitalist is an employee, the employer is required to withhold income, Social Security, and Medicare taxes, and pay unemployment tax on wages paid to the hospitalist. Conversely, if a hospitalist is an independent contractor, the practice or hospital will not withhold or pay taxes on payments to the hospitalist; rather, the individual hospitalist will be responsible for making those payments to the IRS and state tax authorities. It is imperative that the contract clearly indicates whether the hospitalist is an employee or an independent contractor, as well as the corresponding responsibilities of the parties.

Compensation and Benefits

Partial compensation for part-time work is logical, but determining a fair and competitive compensation package is not always as straightforward when it comes to part-timers. There are two general models that practices and hospitals use to determine compensation for hospitalists working part time. First, the physician may be paid a percentage of a full-time physician’s salary, based on the number of hours worked. Second, the physician may receive a per diem rate or an hourly rate. As with full-time physicians, there are various ways to formulate a part-time physician’s compensation, and the method used should be explicitly outlined in the physician’s employment or independent contractor agreement.

Benefit plans and arrangements (such as health, dental, vision, retirement plan, pension plan, disability coverage, life insurance, etc.) frequently are provided to employees and infrequently provided to independent contractors. Whether a physician who is working part time will receive benefits will vary from employer to employer. A threshold issue, however, is whether a part-time worker is even eligible to receive certain benefits. Many health, dental, and vision plans require employees to work a minimum of 30 hours a week on a regular basis, thus excluding part-time employees who work fewer hours. For retirement and pension plans, employees typically must work a minimum of 1,000 hours per year to be eligible to participate. Even if a hospitalist’s employment agreement provides that the hospitalist may receive benefits from the employer, the agreement may also provide that such a provision is subject to the terms and conditions of the particular benefit plans or arrangements.

Professional Liability (Malpractice) Insurance

While some practices or hospitals pay for a part-time physician’s malpractice insurance premiums, many shift some or all of these costs to the physician. Many insurance providers offer malpractice plans for physicians practicing part time, with reduced premiums and reduced coverage.

When negotiating a compensation package, payment for malpractice insurance should be considered. A physician also must be aware of what is excluded from coverage. For example, if a physician works part time with Hospital A and part time with Hospital B, and Hospital A provides malpractice coverage for the physician, it cannot be assumed that such coverage will cover the physician’s work with Hospital B. In this case, the physician may need a separate policy for work performed through Hospital B.

Restrictive Covenants

Although a physician might only be employed on a part-time basis, the employer might nevertheless want to protect itself by including restrictive covenants (i.e. noncompetition and nonsolicitation clauses) in the physician’s employment agreement. A part-time physician must be careful that the restrictive covenants do not jeopardize their other career objectives. For example, in the example described above with the physician working part time for both Hospital A and Hospital B, a noncompetition clause in the physician’s employment agreement with Hospital A could prohibit the physician from working at another hospital, including Hospital B.

Retaining part-time hospitalists is an increasingly attractive option for physician practices and hospitals, and part-time work is an increasingly attractive option for physicians. The items described above are just a few of the provisions that are unique to the part-time physician relationship that should be reflected in the physician’s employment or independent contractor agreement.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at sharris@mcdonaldhopkins.com.

Edward Ma, MD, wasn’t sure what he wanted to be when he grew up. As a biology student at the University of Pennsylvania in Philadelphia, he says friends “peer-pressured” him to choose a career in medicine. Once the decision was made and he began his training, he found out he was pretty good at the doctor thing.

“I realized that I like this,” he says. “I told myself, ‘I’m going to go for it.’”

Dr. Ma also realized he had a liking for business, and where better to study business than at Penn’s Wharton School of Business? He hasn’t completed an MBA, but he’s taken post-grad courses focused on healthcare management. And now he’s combining that knowledge with his experiences as a hospitalist and medical director to develop a consulting business.

“That sort of evolved because I sort of have a big mouth. When I see something wrong, or something that could be done better, I tend to vocalize it,” says Dr. Ma, medical director of hospitalist services at 168-bed Brandywine Hospital in Coatesville, Pa. “The biggest opportunity is to really help a hospitalist group realize its potential and its value.”

Dr. Ma joined Team Hospitalist in April 2012. Although his side business is evolving via “word of mouth,” he still spends the majority of his time in the hospital directing a six-member HM group and caring for hospitalized patients.

Question: What do you like most about caring for patients?

Answer: I like the acuity of the care. The acuity of the illness is pretty high for our patients, and you can see very quickly the impact hospitalists can have. A lot of outpatient medicine is preventive care, so usually you don’t have an immediate problem that needs to be fixed, whereas in HM, the patients are acutely ill and there’s an ability to get these patients better—and see a change in their medical condition in a day or two. There’s more immediate gratification in terms of the effort that we put in caring for a patient.

Q: What do you like least?

A: The paperwork. At my hospital, a lot of it is computerized. But there are tons of checklists, tons of quality measures that need to be addressed, which is good. Still, it ends up bogging down our ability to take care of the patient. For example, a patient comes in for pneumonia and you have to make sure that some of their chronic issues (e.g. diabetes) are addressed. Have they had their hemoglobin A1C checked in the last 60 days? Does it really matter right now when we’re taking care of the patient’s pneumonia that we have to address this? Smoking cessation, yes, it’s very important, and we need to address this, but is it really necessary that we do this at this point when a patient is really ill? I think there’s a lot of these government regulations that they want us to take care of sometimes in the acute setting, which sometimes feels awkward or not necessarily time-appropriate.

Q: You say your training as an internist prepared you for a seamless transition to a hospitalist job, but you also think IM training is “doing a disservice to medicine.” How so?

A: Don’t get me wrong, I love hospital medicine. But I think what we really need is more primary-care doctors. This is not just my commentary on hospital medicine, but all subspecialties. I know specifically speaking that we need more outpatient internists, outpatient family physicians. If there are many internists, they’re not going to have as much need for cardiology or GI, or a lot of other subspecialties. There’s enough of a population of internists that would satisfy the need for internists and obviously the need for subspecialties.

Q: What’s the biggest change in HM you’ve witnessed since you started 10 years ago?

A: Our acceptance as a field by the medical community. Other physicians have now come to be very accepting of our role as the primary caretakers of their hospitalized patients.

Q: Do you consider yourself to have an entrepreneurial spirit or are you more of a solutions-oriented physician?

A: I have more of the entrepreneurial spirit. I’ve been talking to a lot of hospitalists, and what I encourage them to do is completely counter to the current healthcare environment. I’ve been encouraging them to say, “Let’s get a bunch of us together and set up our own hospitalist practice and do it in a way that we can have a certain level of autonomy, but also do it in a way that we can collaborate with the hospital, work intimately with them, and get certain guarantees from them. And do it privately, so that we can maintain our autonomy.” I think that’s important because I see the difference between the private practices and the practices that are owned by a health system. People just care so much more when it’s their own practice.

Q: What are the biggest challenges you face as medical director?

A: Getting everyone to work as a team. Everyone has a different schedule, differing values, and priorities. It’s very important that we work as a team because when one person does something, it impacts what somebody else does.

Q: What’s the most important thing to know when starting an HM group or fixing a broken group?

A: For fixing a group, you have to look at the values of the group of doctors. What are the values? What are the objectives? What are the professional goals? What I’ve encountered in HM is a lot of people are just coming in to get a paycheck. They come in, they do their job, and they like to take care of patients. Don’t get me wrong about that, but they like the freedom and the high competition that’s provided by hospital medicine. Oftentimes they come in, they do their jobs very well, they take care of their patients, and then they’re out the door. They don’t really have an interest in building up that practice or building up something for the hospital. We as doctors are all part of a medical community, we’re part of a medical staff, and it’s very important for us to get involved.

Q: Last year, you became president of SHM’s Philadelphia Tri-State Region chapter. What are your goals?

A: I’ve always been involved with the chapter, but I saw it as a good opportunity to network and talk with more hospitalists. I wanted to get their viewpoints on things and bounce ideas. I’m a very vocal person, so when I hear a good idea, I like to spread it amongst other people. And if I see something that someone said was bad and I hear it from enough people, I like to bring it up and discuss with everybody.

Q: What’s the best part of being an SHM member?

A: Getting to interact with a lot of my colleagues. To see what struggles they’re going through, to see that their struggles are very similar to the struggles that my group is going through, that we’re all in the same boat, and that we need to collaborate a little more to make things work. Instead of each practice trying to reinvent the wheel, we can try to work together and build off each other.

Richard Quinn is a freelance writer in New Jersey.

Edward Ma, MD, wasn’t sure what he wanted to be when he grew up. As a biology student at the University of Pennsylvania in Philadelphia, he says friends “peer-pressured” him to choose a career in medicine. Once the decision was made and he began his training, he found out he was pretty good at the doctor thing.

“I realized that I like this,” he says. “I told myself, ‘I’m going to go for it.’”

Dr. Ma also realized he had a liking for business, and where better to study business than at Penn’s Wharton School of Business? He hasn’t completed an MBA, but he’s taken post-grad courses focused on healthcare management. And now he’s combining that knowledge with his experiences as a hospitalist and medical director to develop a consulting business.

“That sort of evolved because I sort of have a big mouth. When I see something wrong, or something that could be done better, I tend to vocalize it,” says Dr. Ma, medical director of hospitalist services at 168-bed Brandywine Hospital in Coatesville, Pa. “The biggest opportunity is to really help a hospitalist group realize its potential and its value.”

Dr. Ma joined Team Hospitalist in April 2012. Although his side business is evolving via “word of mouth,” he still spends the majority of his time in the hospital directing a six-member HM group and caring for hospitalized patients.

Question: What do you like most about caring for patients?

Answer: I like the acuity of the care. The acuity of the illness is pretty high for our patients, and you can see very quickly the impact hospitalists can have. A lot of outpatient medicine is preventive care, so usually you don’t have an immediate problem that needs to be fixed, whereas in HM, the patients are acutely ill and there’s an ability to get these patients better—and see a change in their medical condition in a day or two. There’s more immediate gratification in terms of the effort that we put in caring for a patient.

Q: What do you like least?

A: The paperwork. At my hospital, a lot of it is computerized. But there are tons of checklists, tons of quality measures that need to be addressed, which is good. Still, it ends up bogging down our ability to take care of the patient. For example, a patient comes in for pneumonia and you have to make sure that some of their chronic issues (e.g. diabetes) are addressed. Have they had their hemoglobin A1C checked in the last 60 days? Does it really matter right now when we’re taking care of the patient’s pneumonia that we have to address this? Smoking cessation, yes, it’s very important, and we need to address this, but is it really necessary that we do this at this point when a patient is really ill? I think there’s a lot of these government regulations that they want us to take care of sometimes in the acute setting, which sometimes feels awkward or not necessarily time-appropriate.

Q: You say your training as an internist prepared you for a seamless transition to a hospitalist job, but you also think IM training is “doing a disservice to medicine.” How so?

A: Don’t get me wrong, I love hospital medicine. But I think what we really need is more primary-care doctors. This is not just my commentary on hospital medicine, but all subspecialties. I know specifically speaking that we need more outpatient internists, outpatient family physicians. If there are many internists, they’re not going to have as much need for cardiology or GI, or a lot of other subspecialties. There’s enough of a population of internists that would satisfy the need for internists and obviously the need for subspecialties.

Q: What’s the biggest change in HM you’ve witnessed since you started 10 years ago?

A: Our acceptance as a field by the medical community. Other physicians have now come to be very accepting of our role as the primary caretakers of their hospitalized patients.

Q: Do you consider yourself to have an entrepreneurial spirit or are you more of a solutions-oriented physician?

A: I have more of the entrepreneurial spirit. I’ve been talking to a lot of hospitalists, and what I encourage them to do is completely counter to the current healthcare environment. I’ve been encouraging them to say, “Let’s get a bunch of us together and set up our own hospitalist practice and do it in a way that we can have a certain level of autonomy, but also do it in a way that we can collaborate with the hospital, work intimately with them, and get certain guarantees from them. And do it privately, so that we can maintain our autonomy.” I think that’s important because I see the difference between the private practices and the practices that are owned by a health system. People just care so much more when it’s their own practice.

Q: What are the biggest challenges you face as medical director?

A: Getting everyone to work as a team. Everyone has a different schedule, differing values, and priorities. It’s very important that we work as a team because when one person does something, it impacts what somebody else does.

Q: What’s the most important thing to know when starting an HM group or fixing a broken group?

A: For fixing a group, you have to look at the values of the group of doctors. What are the values? What are the objectives? What are the professional goals? What I’ve encountered in HM is a lot of people are just coming in to get a paycheck. They come in, they do their job, and they like to take care of patients. Don’t get me wrong about that, but they like the freedom and the high competition that’s provided by hospital medicine. Oftentimes they come in, they do their jobs very well, they take care of their patients, and then they’re out the door. They don’t really have an interest in building up that practice or building up something for the hospital. We as doctors are all part of a medical community, we’re part of a medical staff, and it’s very important for us to get involved.

Q: Last year, you became president of SHM’s Philadelphia Tri-State Region chapter. What are your goals?

A: I’ve always been involved with the chapter, but I saw it as a good opportunity to network and talk with more hospitalists. I wanted to get their viewpoints on things and bounce ideas. I’m a very vocal person, so when I hear a good idea, I like to spread it amongst other people. And if I see something that someone said was bad and I hear it from enough people, I like to bring it up and discuss with everybody.

Q: What’s the best part of being an SHM member?

A: Getting to interact with a lot of my colleagues. To see what struggles they’re going through, to see that their struggles are very similar to the struggles that my group is going through, that we’re all in the same boat, and that we need to collaborate a little more to make things work. Instead of each practice trying to reinvent the wheel, we can try to work together and build off each other.

Richard Quinn is a freelance writer in New Jersey.

Edward Ma, MD, wasn’t sure what he wanted to be when he grew up. As a biology student at the University of Pennsylvania in Philadelphia, he says friends “peer-pressured” him to choose a career in medicine. Once the decision was made and he began his training, he found out he was pretty good at the doctor thing.

“I realized that I like this,” he says. “I told myself, ‘I’m going to go for it.’”

Dr. Ma also realized he had a liking for business, and where better to study business than at Penn’s Wharton School of Business? He hasn’t completed an MBA, but he’s taken post-grad courses focused on healthcare management. And now he’s combining that knowledge with his experiences as a hospitalist and medical director to develop a consulting business.

“That sort of evolved because I sort of have a big mouth. When I see something wrong, or something that could be done better, I tend to vocalize it,” says Dr. Ma, medical director of hospitalist services at 168-bed Brandywine Hospital in Coatesville, Pa. “The biggest opportunity is to really help a hospitalist group realize its potential and its value.”

Dr. Ma joined Team Hospitalist in April 2012. Although his side business is evolving via “word of mouth,” he still spends the majority of his time in the hospital directing a six-member HM group and caring for hospitalized patients.

Question: What do you like most about caring for patients?

Answer: I like the acuity of the care. The acuity of the illness is pretty high for our patients, and you can see very quickly the impact hospitalists can have. A lot of outpatient medicine is preventive care, so usually you don’t have an immediate problem that needs to be fixed, whereas in HM, the patients are acutely ill and there’s an ability to get these patients better—and see a change in their medical condition in a day or two. There’s more immediate gratification in terms of the effort that we put in caring for a patient.

Q: What do you like least?

A: The paperwork. At my hospital, a lot of it is computerized. But there are tons of checklists, tons of quality measures that need to be addressed, which is good. Still, it ends up bogging down our ability to take care of the patient. For example, a patient comes in for pneumonia and you have to make sure that some of their chronic issues (e.g. diabetes) are addressed. Have they had their hemoglobin A1C checked in the last 60 days? Does it really matter right now when we’re taking care of the patient’s pneumonia that we have to address this? Smoking cessation, yes, it’s very important, and we need to address this, but is it really necessary that we do this at this point when a patient is really ill? I think there’s a lot of these government regulations that they want us to take care of sometimes in the acute setting, which sometimes feels awkward or not necessarily time-appropriate.

Q: You say your training as an internist prepared you for a seamless transition to a hospitalist job, but you also think IM training is “doing a disservice to medicine.” How so?

A: Don’t get me wrong, I love hospital medicine. But I think what we really need is more primary-care doctors. This is not just my commentary on hospital medicine, but all subspecialties. I know specifically speaking that we need more outpatient internists, outpatient family physicians. If there are many internists, they’re not going to have as much need for cardiology or GI, or a lot of other subspecialties. There’s enough of a population of internists that would satisfy the need for internists and obviously the need for subspecialties.

Q: What’s the biggest change in HM you’ve witnessed since you started 10 years ago?

A: Our acceptance as a field by the medical community. Other physicians have now come to be very accepting of our role as the primary caretakers of their hospitalized patients.

Q: Do you consider yourself to have an entrepreneurial spirit or are you more of a solutions-oriented physician?

A: I have more of the entrepreneurial spirit. I’ve been talking to a lot of hospitalists, and what I encourage them to do is completely counter to the current healthcare environment. I’ve been encouraging them to say, “Let’s get a bunch of us together and set up our own hospitalist practice and do it in a way that we can have a certain level of autonomy, but also do it in a way that we can collaborate with the hospital, work intimately with them, and get certain guarantees from them. And do it privately, so that we can maintain our autonomy.” I think that’s important because I see the difference between the private practices and the practices that are owned by a health system. People just care so much more when it’s their own practice.

Q: What are the biggest challenges you face as medical director?

A: Getting everyone to work as a team. Everyone has a different schedule, differing values, and priorities. It’s very important that we work as a team because when one person does something, it impacts what somebody else does.

Q: What’s the most important thing to know when starting an HM group or fixing a broken group?

A: For fixing a group, you have to look at the values of the group of doctors. What are the values? What are the objectives? What are the professional goals? What I’ve encountered in HM is a lot of people are just coming in to get a paycheck. They come in, they do their job, and they like to take care of patients. Don’t get me wrong about that, but they like the freedom and the high competition that’s provided by hospital medicine. Oftentimes they come in, they do their jobs very well, they take care of their patients, and then they’re out the door. They don’t really have an interest in building up that practice or building up something for the hospital. We as doctors are all part of a medical community, we’re part of a medical staff, and it’s very important for us to get involved.

Q: Last year, you became president of SHM’s Philadelphia Tri-State Region chapter. What are your goals?

A: I’ve always been involved with the chapter, but I saw it as a good opportunity to network and talk with more hospitalists. I wanted to get their viewpoints on things and bounce ideas. I’m a very vocal person, so when I hear a good idea, I like to spread it amongst other people. And if I see something that someone said was bad and I hear it from enough people, I like to bring it up and discuss with everybody.

Q: What’s the best part of being an SHM member?

A: Getting to interact with a lot of my colleagues. To see what struggles they’re going through, to see that their struggles are very similar to the struggles that my group is going through, that we’re all in the same boat, and that we need to collaborate a little more to make things work. Instead of each practice trying to reinvent the wheel, we can try to work together and build off each other.

Richard Quinn is a freelance writer in New Jersey.

Hospice care” and “palliative care” are not synonymous terms. Hospice care is defined as a comprehensive set of services (see “Hospice Coverage,” below) identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care.¹ Palliative care is defined as patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs, and facilitates patient autonomy, access to information, and choice.¹

As an approach, hospice care of terminally ill individuals involves palliative care (relief of pain and uncomfortable symptoms), and emphasizes maintaining the patient at home with family and friends as long as possible. Hospice services can be provided in a home, center, skilled-nursing facility, or hospital setting. In contrast, palliative-care services can be provided during hospice care, or coincide with care that is focused on a cure.

Many hospitalists provide both hospice care and palliative-care services to their patients. Different factors affect how to report these services. These programs can be quite costly, as they involve several team members and a substantial amount of time delivering these services. Capturing services appropriately and obtaining reimbursement to help continue program initiatives are significant issues.

Hospice Care

When a patient enrolls in hospice, all rights to Medicare Part B payments are waived during the benefit period involving professional services related to the treatment and management of the terminal illness. Payment is made through the Part A benefit for the associated costs of daily care and the services provided by the hospice-employed physician. An exception occurs for professional services of an independent attending physician who is not an employee of the designated hospice and does not receive compensation from the hospice for those services. The “attending physician” for hospice services must be an individual who is a doctor of medicine or osteopathy, or a nurse practitioner identified by the individual, at the time they elect hospice coverage, as having the most significant role in the determination and delivery of their medical care.²

Patients often receive hospice in the hospital setting, where the hospitalist manages the patient’s daily care. If the hospitalist is designated as the “attending physician” for hospice services, the visits should be reported to Medicare Part B with modifier GV (e.g. 99232-GV).3 This will allow for separate payment to the hospitalist (the independent attending physician), while the hospice agency maintains its daily-care rate. Reporting services absent this modifier will result in denial.

In some cases, the hospitalist is not identified as the “attending physician” for hospice services but occasionally provides care related to the terminal illness. This situation proves most difficult. Although the hospitalist might be the most accessible physician to the staff and is putting the patient’s needs first, reimbursement is unlikely. Regulations stipulate that patients must not see independent physicians other than their “attending physician” for care related to their terminal illness unless the hospice arranges it. When the service is related to the hospice patient’s terminal illness but was furnished by someone other than the designated “attending physician,” this “other physician” must look to the hospice for payment.³

Nonhospice Palliative Care

Members of the palliative-care team often are called to provide management options to assist in reducing pain and suffering. When the palliative-care specialist is asked to provide opinions or advice, the initial service may qualify as a consultation for those payors that still recognize these codes. However, all of the requirements⁴ must be met in order to report the service as an inpatient consultation (99251-99255):³

• There must be a written request from a qualified healthcare provider who is involved in the patient’s care (e.g. physician, resident, nurse practitioner); this may be documented as a physician order or in the assessment/plan of the requesting provider’s progress note. Standing orders for consultation are not permitted.
• The requesting provider should clearly and accurately identify the reason for consult request to support the medical necessity of the service.
• The palliative-care physician renders and documents the service.
• The palliative-care physician reports his or her findings to the requesting physician via written communication; because the requesting physician and the consultant share a common inpatient medical record, the consultant’s inpatient progress note satisfies the “written report” requirement.

Consider the nature of the request when reporting a consultation. If the request demonstrates the need for opinions or advice from the palliative-care specialist, the service can be reported as a consultation. If the indication cites “medical management” or “palliative management,” payors are less likely to consider the service as a consultation because the physician is not seeking opinions or advice from the consultant to incorporate into his or her own plan of care for the patient and would rather the consultant just take over that portion of patient care. When consultations do not meet the requirements, subsequent hospital care services should be reported (99231-99233).³

The requesting physician can be in the same or a different provider group as the consultant. The consultant must possess expertise in an area that is beyond that of the requesting provider. Because most hospitalists carry a specialty designation of internal medicine (physician specialty code 11), hospitalists providing palliative-care services can distinguish themselves by their own code (physician specialty code 17, hospice and palliative care).⁵ Payor concerns arise when physicians of the same designated specialty submit a claim for the same patient on the same date. The payor is likely to pay the first claim received and deny the second claim received pending review of documentation. If this occurs, submit a copy of both progress notes for the date in question to distinguish the services provided. The payor may still require that both encounters be reported as one cumulative service under one physician.

Consultations are not an option for Medicare beneficiaries. Hospitalists providing palliative care can report initial hospital care codes (99221-99223) for their first encounter with the patient.³ This is only acceptable when no other hospitalist from the group has reported initial hospital care during the patient stay, unless the palliative-care hospitalist carries the corresponding designation (i.e. enrolled with Medicare as physician specialty code 17). Without this separate designation, the palliative-care hospitalist can only report subsequent hospital care codes (99231-99233) as the patient was seen previously by a hospitalist in the same group.³

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. U.S. Government Printing Office. Electronic Code of Federal Regulations: Title 42: Public Health, Part 418: Hospice Care, §418.3. June 2012. U.S. Government Printing Office website. Available at: http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=818258235647b14d2961ad30fa3e68e6&rgn=div5&view=text&node=42:3.0.1.1.5&idno=42#42:3.0.1.1.5.1.3.3. Accessed June 23, 2012.
2. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 11: processing hospice claims. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c11.pdf. Accessed June 23, 2012.
3. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
4. American Medical Association. Consultation services and transfer of care. American Medical Association website. Available at: http://www.ama-assn.org/resources/doc/cpt/cpt-consultation-services.pdf. Accessed June 23, 2012.
5. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 26: completing and processing form CMS-1500 data set. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf. Accessed June 23, 2012. Department of Health and Human Services.
6. Hospice Payment System: payment system fact sheet series. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/hospice_pay_sys_fs.pdf. Accessed June 23, 2012.

Hospice care” and “palliative care” are not synonymous terms. Hospice care is defined as a comprehensive set of services (see “Hospice Coverage,” below) identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care.¹ Palliative care is defined as patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs, and facilitates patient autonomy, access to information, and choice.¹

As an approach, hospice care of terminally ill individuals involves palliative care (relief of pain and uncomfortable symptoms), and emphasizes maintaining the patient at home with family and friends as long as possible. Hospice services can be provided in a home, center, skilled-nursing facility, or hospital setting. In contrast, palliative-care services can be provided during hospice care, or coincide with care that is focused on a cure.

Many hospitalists provide both hospice care and palliative-care services to their patients. Different factors affect how to report these services. These programs can be quite costly, as they involve several team members and a substantial amount of time delivering these services. Capturing services appropriately and obtaining reimbursement to help continue program initiatives are significant issues.

Hospice Care

When a patient enrolls in hospice, all rights to Medicare Part B payments are waived during the benefit period involving professional services related to the treatment and management of the terminal illness. Payment is made through the Part A benefit for the associated costs of daily care and the services provided by the hospice-employed physician. An exception occurs for professional services of an independent attending physician who is not an employee of the designated hospice and does not receive compensation from the hospice for those services. The “attending physician” for hospice services must be an individual who is a doctor of medicine or osteopathy, or a nurse practitioner identified by the individual, at the time they elect hospice coverage, as having the most significant role in the determination and delivery of their medical care.²

Patients often receive hospice in the hospital setting, where the hospitalist manages the patient’s daily care. If the hospitalist is designated as the “attending physician” for hospice services, the visits should be reported to Medicare Part B with modifier GV (e.g. 99232-GV).3 This will allow for separate payment to the hospitalist (the independent attending physician), while the hospice agency maintains its daily-care rate. Reporting services absent this modifier will result in denial.

In some cases, the hospitalist is not identified as the “attending physician” for hospice services but occasionally provides care related to the terminal illness. This situation proves most difficult. Although the hospitalist might be the most accessible physician to the staff and is putting the patient’s needs first, reimbursement is unlikely. Regulations stipulate that patients must not see independent physicians other than their “attending physician” for care related to their terminal illness unless the hospice arranges it. When the service is related to the hospice patient’s terminal illness but was furnished by someone other than the designated “attending physician,” this “other physician” must look to the hospice for payment.³

Nonhospice Palliative Care

Members of the palliative-care team often are called to provide management options to assist in reducing pain and suffering. When the palliative-care specialist is asked to provide opinions or advice, the initial service may qualify as a consultation for those payors that still recognize these codes. However, all of the requirements⁴ must be met in order to report the service as an inpatient consultation (99251-99255):³

• There must be a written request from a qualified healthcare provider who is involved in the patient’s care (e.g. physician, resident, nurse practitioner); this may be documented as a physician order or in the assessment/plan of the requesting provider’s progress note. Standing orders for consultation are not permitted.
• The requesting provider should clearly and accurately identify the reason for consult request to support the medical necessity of the service.
• The palliative-care physician renders and documents the service.
• The palliative-care physician reports his or her findings to the requesting physician via written communication; because the requesting physician and the consultant share a common inpatient medical record, the consultant’s inpatient progress note satisfies the “written report” requirement.

Consider the nature of the request when reporting a consultation. If the request demonstrates the need for opinions or advice from the palliative-care specialist, the service can be reported as a consultation. If the indication cites “medical management” or “palliative management,” payors are less likely to consider the service as a consultation because the physician is not seeking opinions or advice from the consultant to incorporate into his or her own plan of care for the patient and would rather the consultant just take over that portion of patient care. When consultations do not meet the requirements, subsequent hospital care services should be reported (99231-99233).³

The requesting physician can be in the same or a different provider group as the consultant. The consultant must possess expertise in an area that is beyond that of the requesting provider. Because most hospitalists carry a specialty designation of internal medicine (physician specialty code 11), hospitalists providing palliative-care services can distinguish themselves by their own code (physician specialty code 17, hospice and palliative care).⁵ Payor concerns arise when physicians of the same designated specialty submit a claim for the same patient on the same date. The payor is likely to pay the first claim received and deny the second claim received pending review of documentation. If this occurs, submit a copy of both progress notes for the date in question to distinguish the services provided. The payor may still require that both encounters be reported as one cumulative service under one physician.

Consultations are not an option for Medicare beneficiaries. Hospitalists providing palliative care can report initial hospital care codes (99221-99223) for their first encounter with the patient.³ This is only acceptable when no other hospitalist from the group has reported initial hospital care during the patient stay, unless the palliative-care hospitalist carries the corresponding designation (i.e. enrolled with Medicare as physician specialty code 17). Without this separate designation, the palliative-care hospitalist can only report subsequent hospital care codes (99231-99233) as the patient was seen previously by a hospitalist in the same group.³

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. U.S. Government Printing Office. Electronic Code of Federal Regulations: Title 42: Public Health, Part 418: Hospice Care, §418.3. June 2012. U.S. Government Printing Office website. Available at: http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=818258235647b14d2961ad30fa3e68e6&rgn=div5&view=text&node=42:3.0.1.1.5&idno=42#42:3.0.1.1.5.1.3.3. Accessed June 23, 2012.
2. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 11: processing hospice claims. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c11.pdf. Accessed June 23, 2012.
3. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
4. American Medical Association. Consultation services and transfer of care. American Medical Association website. Available at: http://www.ama-assn.org/resources/doc/cpt/cpt-consultation-services.pdf. Accessed June 23, 2012.
5. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 26: completing and processing form CMS-1500 data set. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf. Accessed June 23, 2012. Department of Health and Human Services.
6. Hospice Payment System: payment system fact sheet series. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/hospice_pay_sys_fs.pdf. Accessed June 23, 2012.

Hospice care” and “palliative care” are not synonymous terms. Hospice care is defined as a comprehensive set of services (see “Hospice Coverage,” below) identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care.¹ Palliative care is defined as patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs, and facilitates patient autonomy, access to information, and choice.¹

As an approach, hospice care of terminally ill individuals involves palliative care (relief of pain and uncomfortable symptoms), and emphasizes maintaining the patient at home with family and friends as long as possible. Hospice services can be provided in a home, center, skilled-nursing facility, or hospital setting. In contrast, palliative-care services can be provided during hospice care, or coincide with care that is focused on a cure.

Many hospitalists provide both hospice care and palliative-care services to their patients. Different factors affect how to report these services. These programs can be quite costly, as they involve several team members and a substantial amount of time delivering these services. Capturing services appropriately and obtaining reimbursement to help continue program initiatives are significant issues.

Hospice Care

When a patient enrolls in hospice, all rights to Medicare Part B payments are waived during the benefit period involving professional services related to the treatment and management of the terminal illness. Payment is made through the Part A benefit for the associated costs of daily care and the services provided by the hospice-employed physician. An exception occurs for professional services of an independent attending physician who is not an employee of the designated hospice and does not receive compensation from the hospice for those services. The “attending physician” for hospice services must be an individual who is a doctor of medicine or osteopathy, or a nurse practitioner identified by the individual, at the time they elect hospice coverage, as having the most significant role in the determination and delivery of their medical care.²

Patients often receive hospice in the hospital setting, where the hospitalist manages the patient’s daily care. If the hospitalist is designated as the “attending physician” for hospice services, the visits should be reported to Medicare Part B with modifier GV (e.g. 99232-GV).3 This will allow for separate payment to the hospitalist (the independent attending physician), while the hospice agency maintains its daily-care rate. Reporting services absent this modifier will result in denial.

In some cases, the hospitalist is not identified as the “attending physician” for hospice services but occasionally provides care related to the terminal illness. This situation proves most difficult. Although the hospitalist might be the most accessible physician to the staff and is putting the patient’s needs first, reimbursement is unlikely. Regulations stipulate that patients must not see independent physicians other than their “attending physician” for care related to their terminal illness unless the hospice arranges it. When the service is related to the hospice patient’s terminal illness but was furnished by someone other than the designated “attending physician,” this “other physician” must look to the hospice for payment.³

Nonhospice Palliative Care

Members of the palliative-care team often are called to provide management options to assist in reducing pain and suffering. When the palliative-care specialist is asked to provide opinions or advice, the initial service may qualify as a consultation for those payors that still recognize these codes. However, all of the requirements⁴ must be met in order to report the service as an inpatient consultation (99251-99255):³

• There must be a written request from a qualified healthcare provider who is involved in the patient’s care (e.g. physician, resident, nurse practitioner); this may be documented as a physician order or in the assessment/plan of the requesting provider’s progress note. Standing orders for consultation are not permitted.
• The requesting provider should clearly and accurately identify the reason for consult request to support the medical necessity of the service.
• The palliative-care physician renders and documents the service.
• The palliative-care physician reports his or her findings to the requesting physician via written communication; because the requesting physician and the consultant share a common inpatient medical record, the consultant’s inpatient progress note satisfies the “written report” requirement.

Consider the nature of the request when reporting a consultation. If the request demonstrates the need for opinions or advice from the palliative-care specialist, the service can be reported as a consultation. If the indication cites “medical management” or “palliative management,” payors are less likely to consider the service as a consultation because the physician is not seeking opinions or advice from the consultant to incorporate into his or her own plan of care for the patient and would rather the consultant just take over that portion of patient care. When consultations do not meet the requirements, subsequent hospital care services should be reported (99231-99233).³

The requesting physician can be in the same or a different provider group as the consultant. The consultant must possess expertise in an area that is beyond that of the requesting provider. Because most hospitalists carry a specialty designation of internal medicine (physician specialty code 11), hospitalists providing palliative-care services can distinguish themselves by their own code (physician specialty code 17, hospice and palliative care).⁵ Payor concerns arise when physicians of the same designated specialty submit a claim for the same patient on the same date. The payor is likely to pay the first claim received and deny the second claim received pending review of documentation. If this occurs, submit a copy of both progress notes for the date in question to distinguish the services provided. The payor may still require that both encounters be reported as one cumulative service under one physician.

Consultations are not an option for Medicare beneficiaries. Hospitalists providing palliative care can report initial hospital care codes (99221-99223) for their first encounter with the patient.³ This is only acceptable when no other hospitalist from the group has reported initial hospital care during the patient stay, unless the palliative-care hospitalist carries the corresponding designation (i.e. enrolled with Medicare as physician specialty code 17). Without this separate designation, the palliative-care hospitalist can only report subsequent hospital care codes (99231-99233) as the patient was seen previously by a hospitalist in the same group.³

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. U.S. Government Printing Office. Electronic Code of Federal Regulations: Title 42: Public Health, Part 418: Hospice Care, §418.3. June 2012. U.S. Government Printing Office website. Available at: http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=818258235647b14d2961ad30fa3e68e6&rgn=div5&view=text&node=42:3.0.1.1.5&idno=42#42:3.0.1.1.5.1.3.3. Accessed June 23, 2012.
2. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 11: processing hospice claims. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c11.pdf. Accessed June 23, 2012.
3. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
4. American Medical Association. Consultation services and transfer of care. American Medical Association website. Available at: http://www.ama-assn.org/resources/doc/cpt/cpt-consultation-services.pdf. Accessed June 23, 2012.
5. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 26: completing and processing form CMS-1500 data set. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf. Accessed June 23, 2012. Department of Health and Human Services.
6. Hospice Payment System: payment system fact sheet series. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/hospice_pay_sys_fs.pdf. Accessed June 23, 2012.

Dr. Pinson:

Thank you for your inquiry to my June column, which outlined physician reporting of ICD-9-CM diagnoses. Confusion arises because there are two mechanisms for reporting facility-based claims: the professional (physician) bill and the facility bill. ICD-9-CM has been adopted under HIPAA for all healthcare settings. Several components of the ICD-9-CM manual offer instructions on its use. “How to Use the ICD-9-CM for Physicians (Volumes 1&2)” identifies “10 Steps to Correct Coding.”^2,3 Step 1 explicitly denotes the inability to use “rule out,” “suspected,” “probable,” or “questionable” diagnoses, and applies to all professional claims submitted on CMS1500 or electronic equivalent.³

The “ICD-9-CM Official Guidelines for Coding and Reporting” are a set of rules developed to accompany and complement the official conventions and instructions provided within ICD-9-CM and approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare & Medicaid Services (CMS), and NCHS. These guidelines are included on the official government version of the ICD-9-CM, and also appear in “Coding Clinic for ICD-9-CM” published by the AHA.³

While Section I of these guidelines applies to all locations, Sections II and III refer to the selection of the principal diagnosis (the condition established after study to be chiefly responsible for the admission) reported by facilities for DRG payment on CMS1450 or its electronic equivalent.² Since DRG payment is based on the average resources used to treat inpatients, it is allowable to code a properly documented, “uncertain” condition as if it existed or was established. It does not apply to the outpatient setting. Outpatient, facility-based (Section IV) claims follow the same standards as professional claims, which should not list any diagnosis documented as “probable,” “suspected,” “questionable,” “rule out” or “working diagnosis,” or other similar terms indicating uncertainty.

Carol Pohlig, BSN, RN, CPC, ACS, is a contributing writer to The Hospitalist.

References

1. Hart AC, Stegman MS, Ford B, eds. ICD-9-CM for Physicians Volumes 1 & 2 2012 Expert Edition. OptimumInsight; 2011. Page vi.
2. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual. Chapter 23, Section 10A. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c23.pdf. Accessed July 24, 2012.
3. Hart AC, Stegman MS, Ford B. ICD-9-CM for Physicians Volumes 1 & 2 2012 Expert Edition. OptimumInsight; 2011. Page 1.

Dr. Pinson:

Thank you for your inquiry to my June column, which outlined physician reporting of ICD-9-CM diagnoses. Confusion arises because there are two mechanisms for reporting facility-based claims: the professional (physician) bill and the facility bill. ICD-9-CM has been adopted under HIPAA for all healthcare settings. Several components of the ICD-9-CM manual offer instructions on its use. “How to Use the ICD-9-CM for Physicians (Volumes 1&2)” identifies “10 Steps to Correct Coding.”^2,3 Step 1 explicitly denotes the inability to use “rule out,” “suspected,” “probable,” or “questionable” diagnoses, and applies to all professional claims submitted on CMS1500 or electronic equivalent.³

The “ICD-9-CM Official Guidelines for Coding and Reporting” are a set of rules developed to accompany and complement the official conventions and instructions provided within ICD-9-CM and approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare & Medicaid Services (CMS), and NCHS. These guidelines are included on the official government version of the ICD-9-CM, and also appear in “Coding Clinic for ICD-9-CM” published by the AHA.³

While Section I of these guidelines applies to all locations, Sections II and III refer to the selection of the principal diagnosis (the condition established after study to be chiefly responsible for the admission) reported by facilities for DRG payment on CMS1450 or its electronic equivalent.² Since DRG payment is based on the average resources used to treat inpatients, it is allowable to code a properly documented, “uncertain” condition as if it existed or was established. It does not apply to the outpatient setting. Outpatient, facility-based (Section IV) claims follow the same standards as professional claims, which should not list any diagnosis documented as “probable,” “suspected,” “questionable,” “rule out” or “working diagnosis,” or other similar terms indicating uncertainty.

Carol Pohlig, BSN, RN, CPC, ACS, is a contributing writer to The Hospitalist.

References

1. Hart AC, Stegman MS, Ford B, eds. ICD-9-CM for Physicians Volumes 1 & 2 2012 Expert Edition. OptimumInsight; 2011. Page vi.
2. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual. Chapter 23, Section 10A. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c23.pdf. Accessed July 24, 2012.
3. Hart AC, Stegman MS, Ford B. ICD-9-CM for Physicians Volumes 1 & 2 2012 Expert Edition. OptimumInsight; 2011. Page 1.

Dr. Pinson:

Thank you for your inquiry to my June column, which outlined physician reporting of ICD-9-CM diagnoses. Confusion arises because there are two mechanisms for reporting facility-based claims: the professional (physician) bill and the facility bill. ICD-9-CM has been adopted under HIPAA for all healthcare settings. Several components of the ICD-9-CM manual offer instructions on its use. “How to Use the ICD-9-CM for Physicians (Volumes 1&2)” identifies “10 Steps to Correct Coding.”^2,3 Step 1 explicitly denotes the inability to use “rule out,” “suspected,” “probable,” or “questionable” diagnoses, and applies to all professional claims submitted on CMS1500 or electronic equivalent.³

The “ICD-9-CM Official Guidelines for Coding and Reporting” are a set of rules developed to accompany and complement the official conventions and instructions provided within ICD-9-CM and approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare & Medicaid Services (CMS), and NCHS. These guidelines are included on the official government version of the ICD-9-CM, and also appear in “Coding Clinic for ICD-9-CM” published by the AHA.³

While Section I of these guidelines applies to all locations, Sections II and III refer to the selection of the principal diagnosis (the condition established after study to be chiefly responsible for the admission) reported by facilities for DRG payment on CMS1450 or its electronic equivalent.² Since DRG payment is based on the average resources used to treat inpatients, it is allowable to code a properly documented, “uncertain” condition as if it existed or was established. It does not apply to the outpatient setting. Outpatient, facility-based (Section IV) claims follow the same standards as professional claims, which should not list any diagnosis documented as “probable,” “suspected,” “questionable,” “rule out” or “working diagnosis,” or other similar terms indicating uncertainty.

Carol Pohlig, BSN, RN, CPC, ACS, is a contributing writer to The Hospitalist.

References

1. Hart AC, Stegman MS, Ford B, eds. ICD-9-CM for Physicians Volumes 1 & 2 2012 Expert Edition. OptimumInsight; 2011. Page vi.
2. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual. Chapter 23, Section 10A. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c23.pdf. Accessed July 24, 2012.
3. Hart AC, Stegman MS, Ford B. ICD-9-CM for Physicians Volumes 1 & 2 2012 Expert Edition. OptimumInsight; 2011. Page 1.

Hospitalists often are involved in the postoperative care of the surgical patient. However, HM is emerging in the admitting/attending role for procedural patients. Confusion can arise as to the nature of the hospitalist service, and whether it is deemed billable. Knowing the surgical package requirements can help hospitalists consider the issues.

Global Surgical Package Period¹

Surgical procedures, categorized as major or minor surgery, are reimbursed for pre-, intra-, and postoperative care. Postoperative care varies according to the procedure’s assigned global period, which designates zero, 10, or 90 postoperative days. (Physicians can review the global period for any given CPT code in the Medicare Physician Fee Schedule, available at www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx.)

Services classified with “XXX” do not have the global period concept. “ZZZ” services denote an “add-on” procedure code that must always be reported with a primary procedure code and assumes the global period assigned to the primary procedure performed.

Major surgery allocates a 90-day global period in which the surgeon is responsible for all related surgical care one day before surgery through 90 postoperative days with no additional charge. Minor surgery, including endoscopy, appoints a zero-day or 10-day postoperative period. The zero-day global period encompasses only services provided on the surgical day, whereas 10-day global periods include services on the surgical day through 10 postoperative days.

Global Surgical Package Components²

The global surgical package comprises a host of responsibilities that include standard facility requirements of filling out all necessary paperwork involved in surgical cases (e.g. preoperative H&P, operative consent forms, preoperative orders). Additionally, the surgeon’s packaged payment includes (at no extra charge):

• Preoperative visits after making the decision for surgery beginning one day prior to surgery;
• All additional postoperative medical or surgical services provided by the surgeon related to complications but not requiring additional trips to the operating room;
• Postoperative visits by the surgeon related to recovery from surgery, including but not limited to dressing changes; local incisional care; removal of cutaneous sutures and staples; line removals; changes and removal of tracheostomy tubes; and discharge services; and
• Postoperative pain management provided by the surgeon.
• Examples of services that are not included in the global surgical package, (i.e. are separately billable and may require an appropriate modifier) are:
• The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery;
• Services of other physicians except where the other physicians are providing coverage for the surgeon or agree on a transfer of care (i.e. a formal agreement in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record);
• Postoperative visits by the surgeon unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;
• Diagnostic tests and procedures, including diagnostic radiological procedures;
• Clearly distinct surgical procedures during the postoperative period that do not result in repeat operations or treatment for complications;
• Treatment for postoperative complications that requires a return trip to the operating room (OR), catheterization lab or endoscopy suite;
• Immunosuppressive therapy for organ transplants; and
• Critical-care services (CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the surgeon.

Classification of “Surgeon”

For billing purposes, the “surgeon” is a qualified physician who can perform “surgical” services within their scope of practice. All physicians with the same specialty designation in the same group practice as the “surgeon” (i.e. reporting services under the same tax identification number) are considered a single entity and must adhere to the global period billing rules initiated by the “surgeon.”

Alternately, physicians with different specialty designations in the same group practice (e.g. a hospitalist and a cardiologist in a multispecialty group who report services under the same tax identification number) or different group practices can perform and separately report medically necessary services during the surgeon’s global period, as long as a formal (mutually agreed-upon) transfer of care did not occur.

Medical Necessity

With the growth of HM programs and the admission/attending role expansion, involvement in surgical cases comes under scrutiny for medical necessity. Admitting a patient who has active medical conditions (e.g. hypertension, diabetes, emphysema) is reasonable and necessary because the patient has a well-defined need for medical management by the hospitalist. Participation in the care of these patients is separately billable from the surgeon’s global period package.

Alternatively, a hospitalist might be required to admit and follow surgical patients who have no other identifiable chronic or acute conditions aside from the surgical problem. In these cases, hospitalist involvement may satisfy facility policy (quality of care, risk reduction, etc.) and administrative functions (discharge services or coordination of care) rather than active clinical management. This “medical management” will not be considered “medically necessary” by the payor, and may be denied as incidental to the surgeon’s perioperative services. Erroneous payment can occur, which will result in refund requests, as payors do not want to pay twice for duplicate services. Hospitalists can attempt to negotiate other terms with facilities to account for the unpaid time and effort directed toward these types of cases.

Consider the Case

A patient with numerous medical comorbidities is admitted to the hospitalist service for stabilization prior to surgery, which will occur the next day. The hospitalist can report the appropriate admission code (99221-99223) without need for modifiers because the hospitalist is the attending of record and in a different specialty group. If a private insurer denies the claim as inclusive to the surgical service, the hospitalist can appeal with notes and a cover letter, along with the Medicare guidelines for global surgical package. The hospitalist may continue to provide postoperative daily care, as needed, to manage the patient’s chronic conditions, and report each service as subsequent hospital care (99231-99233) without modifier until the day of discharge (99238-99239). Again, if a payor issues a denial (inclusive to surgery), appealing with notes might be necessary.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 40. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed May 5, 2012.
2. Centers for Medicare & Medicaid Services. ICD-10: HHS proposes one-year delay of ICD-10 compliance date. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10. Accessed May 5, 2012.
3. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.

Hospitalists often are involved in the postoperative care of the surgical patient. However, HM is emerging in the admitting/attending role for procedural patients. Confusion can arise as to the nature of the hospitalist service, and whether it is deemed billable. Knowing the surgical package requirements can help hospitalists consider the issues.

Global Surgical Package Period¹

Surgical procedures, categorized as major or minor surgery, are reimbursed for pre-, intra-, and postoperative care. Postoperative care varies according to the procedure’s assigned global period, which designates zero, 10, or 90 postoperative days. (Physicians can review the global period for any given CPT code in the Medicare Physician Fee Schedule, available at www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx.)

Services classified with “XXX” do not have the global period concept. “ZZZ” services denote an “add-on” procedure code that must always be reported with a primary procedure code and assumes the global period assigned to the primary procedure performed.

Major surgery allocates a 90-day global period in which the surgeon is responsible for all related surgical care one day before surgery through 90 postoperative days with no additional charge. Minor surgery, including endoscopy, appoints a zero-day or 10-day postoperative period. The zero-day global period encompasses only services provided on the surgical day, whereas 10-day global periods include services on the surgical day through 10 postoperative days.

Global Surgical Package Components²

The global surgical package comprises a host of responsibilities that include standard facility requirements of filling out all necessary paperwork involved in surgical cases (e.g. preoperative H&P, operative consent forms, preoperative orders). Additionally, the surgeon’s packaged payment includes (at no extra charge):

• Preoperative visits after making the decision for surgery beginning one day prior to surgery;
• All additional postoperative medical or surgical services provided by the surgeon related to complications but not requiring additional trips to the operating room;
• Postoperative visits by the surgeon related to recovery from surgery, including but not limited to dressing changes; local incisional care; removal of cutaneous sutures and staples; line removals; changes and removal of tracheostomy tubes; and discharge services; and
• Postoperative pain management provided by the surgeon.
• Examples of services that are not included in the global surgical package, (i.e. are separately billable and may require an appropriate modifier) are:
• The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery;
• Services of other physicians except where the other physicians are providing coverage for the surgeon or agree on a transfer of care (i.e. a formal agreement in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record);
• Postoperative visits by the surgeon unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;
• Diagnostic tests and procedures, including diagnostic radiological procedures;
• Clearly distinct surgical procedures during the postoperative period that do not result in repeat operations or treatment for complications;
• Treatment for postoperative complications that requires a return trip to the operating room (OR), catheterization lab or endoscopy suite;
• Immunosuppressive therapy for organ transplants; and
• Critical-care services (CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the surgeon.

Classification of “Surgeon”

For billing purposes, the “surgeon” is a qualified physician who can perform “surgical” services within their scope of practice. All physicians with the same specialty designation in the same group practice as the “surgeon” (i.e. reporting services under the same tax identification number) are considered a single entity and must adhere to the global period billing rules initiated by the “surgeon.”

Alternately, physicians with different specialty designations in the same group practice (e.g. a hospitalist and a cardiologist in a multispecialty group who report services under the same tax identification number) or different group practices can perform and separately report medically necessary services during the surgeon’s global period, as long as a formal (mutually agreed-upon) transfer of care did not occur.

Medical Necessity

With the growth of HM programs and the admission/attending role expansion, involvement in surgical cases comes under scrutiny for medical necessity. Admitting a patient who has active medical conditions (e.g. hypertension, diabetes, emphysema) is reasonable and necessary because the patient has a well-defined need for medical management by the hospitalist. Participation in the care of these patients is separately billable from the surgeon’s global period package.

Alternatively, a hospitalist might be required to admit and follow surgical patients who have no other identifiable chronic or acute conditions aside from the surgical problem. In these cases, hospitalist involvement may satisfy facility policy (quality of care, risk reduction, etc.) and administrative functions (discharge services or coordination of care) rather than active clinical management. This “medical management” will not be considered “medically necessary” by the payor, and may be denied as incidental to the surgeon’s perioperative services. Erroneous payment can occur, which will result in refund requests, as payors do not want to pay twice for duplicate services. Hospitalists can attempt to negotiate other terms with facilities to account for the unpaid time and effort directed toward these types of cases.

Consider the Case

A patient with numerous medical comorbidities is admitted to the hospitalist service for stabilization prior to surgery, which will occur the next day. The hospitalist can report the appropriate admission code (99221-99223) without need for modifiers because the hospitalist is the attending of record and in a different specialty group. If a private insurer denies the claim as inclusive to the surgical service, the hospitalist can appeal with notes and a cover letter, along with the Medicare guidelines for global surgical package. The hospitalist may continue to provide postoperative daily care, as needed, to manage the patient’s chronic conditions, and report each service as subsequent hospital care (99231-99233) without modifier until the day of discharge (99238-99239). Again, if a payor issues a denial (inclusive to surgery), appealing with notes might be necessary.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 40. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed May 5, 2012.
2. Centers for Medicare & Medicaid Services. ICD-10: HHS proposes one-year delay of ICD-10 compliance date. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10. Accessed May 5, 2012.
3. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.

Hospitalists often are involved in the postoperative care of the surgical patient. However, HM is emerging in the admitting/attending role for procedural patients. Confusion can arise as to the nature of the hospitalist service, and whether it is deemed billable. Knowing the surgical package requirements can help hospitalists consider the issues.

Global Surgical Package Period¹

Surgical procedures, categorized as major or minor surgery, are reimbursed for pre-, intra-, and postoperative care. Postoperative care varies according to the procedure’s assigned global period, which designates zero, 10, or 90 postoperative days. (Physicians can review the global period for any given CPT code in the Medicare Physician Fee Schedule, available at www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx.)

Services classified with “XXX” do not have the global period concept. “ZZZ” services denote an “add-on” procedure code that must always be reported with a primary procedure code and assumes the global period assigned to the primary procedure performed.

Major surgery allocates a 90-day global period in which the surgeon is responsible for all related surgical care one day before surgery through 90 postoperative days with no additional charge. Minor surgery, including endoscopy, appoints a zero-day or 10-day postoperative period. The zero-day global period encompasses only services provided on the surgical day, whereas 10-day global periods include services on the surgical day through 10 postoperative days.

Global Surgical Package Components²

The global surgical package comprises a host of responsibilities that include standard facility requirements of filling out all necessary paperwork involved in surgical cases (e.g. preoperative H&P, operative consent forms, preoperative orders). Additionally, the surgeon’s packaged payment includes (at no extra charge):

• Preoperative visits after making the decision for surgery beginning one day prior to surgery;
• All additional postoperative medical or surgical services provided by the surgeon related to complications but not requiring additional trips to the operating room;
• Postoperative visits by the surgeon related to recovery from surgery, including but not limited to dressing changes; local incisional care; removal of cutaneous sutures and staples; line removals; changes and removal of tracheostomy tubes; and discharge services; and
• Postoperative pain management provided by the surgeon.
• Examples of services that are not included in the global surgical package, (i.e. are separately billable and may require an appropriate modifier) are:
• The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery;
• Services of other physicians except where the other physicians are providing coverage for the surgeon or agree on a transfer of care (i.e. a formal agreement in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record);
• Postoperative visits by the surgeon unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;
• Diagnostic tests and procedures, including diagnostic radiological procedures;
• Clearly distinct surgical procedures during the postoperative period that do not result in repeat operations or treatment for complications;
• Treatment for postoperative complications that requires a return trip to the operating room (OR), catheterization lab or endoscopy suite;
• Immunosuppressive therapy for organ transplants; and
• Critical-care services (CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the surgeon.

Classification of “Surgeon”

For billing purposes, the “surgeon” is a qualified physician who can perform “surgical” services within their scope of practice. All physicians with the same specialty designation in the same group practice as the “surgeon” (i.e. reporting services under the same tax identification number) are considered a single entity and must adhere to the global period billing rules initiated by the “surgeon.”

Alternately, physicians with different specialty designations in the same group practice (e.g. a hospitalist and a cardiologist in a multispecialty group who report services under the same tax identification number) or different group practices can perform and separately report medically necessary services during the surgeon’s global period, as long as a formal (mutually agreed-upon) transfer of care did not occur.

Medical Necessity

With the growth of HM programs and the admission/attending role expansion, involvement in surgical cases comes under scrutiny for medical necessity. Admitting a patient who has active medical conditions (e.g. hypertension, diabetes, emphysema) is reasonable and necessary because the patient has a well-defined need for medical management by the hospitalist. Participation in the care of these patients is separately billable from the surgeon’s global period package.

Alternatively, a hospitalist might be required to admit and follow surgical patients who have no other identifiable chronic or acute conditions aside from the surgical problem. In these cases, hospitalist involvement may satisfy facility policy (quality of care, risk reduction, etc.) and administrative functions (discharge services or coordination of care) rather than active clinical management. This “medical management” will not be considered “medically necessary” by the payor, and may be denied as incidental to the surgeon’s perioperative services. Erroneous payment can occur, which will result in refund requests, as payors do not want to pay twice for duplicate services. Hospitalists can attempt to negotiate other terms with facilities to account for the unpaid time and effort directed toward these types of cases.

Consider the Case

A patient with numerous medical comorbidities is admitted to the hospitalist service for stabilization prior to surgery, which will occur the next day. The hospitalist can report the appropriate admission code (99221-99223) without need for modifiers because the hospitalist is the attending of record and in a different specialty group. If a private insurer denies the claim as inclusive to the surgical service, the hospitalist can appeal with notes and a cover letter, along with the Medicare guidelines for global surgical package. The hospitalist may continue to provide postoperative daily care, as needed, to manage the patient’s chronic conditions, and report each service as subsequent hospital care (99231-99233) without modifier until the day of discharge (99238-99239). Again, if a payor issues a denial (inclusive to surgery), appealing with notes might be necessary.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 40. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed May 5, 2012.
2. Centers for Medicare & Medicaid Services. ICD-10: HHS proposes one-year delay of ICD-10 compliance date. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10. Accessed May 5, 2012.
3. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.

Under Section 1862(a)(1)(A) of the Social Security Act, the Medicare program may only pay for items and services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,” unless there is another statutory authorization for payment (e.g. colorectal cancer screening).¹ Coverage limitations include:²

• Proven clinical efficacy. For example, Medicare deems acupuncture “experimental/investigational” in the diagnosis or treatment of illness or injury;
• Diagnoses. As an example, vitamin B-12 injections are covered, but only for such diagnoses as pernicious anemia and dementias secondary to vitamin B-12 deficiency; and
• Frequency/utilization parameters. For example, a screening colonoscopy (G0105) can be paid once every 24 months for beneficiaries who are at high risk for colorectal cancer; otherwise the service is limited to once every 10 years.

Beyond these factors, individual consideration might be granted. Supportive and unambiguous documentation (medical records, clinical studies, etc.) must be submitted when the clinical circumstances do not appear to support the medical necessity for the service.

Diagnoses Selection

Select the code that best represents the primary reason for the service or procedure on a given date. In the absence of a definitive diagnosis, the code may correspond to a sign or symptom. Physicians never should report a code that represents a probable, suspected, or “rule out” condition. Although facility billing might consider these unconfirmed circumstances (when necessary), physician billing prohibits this practice.

Reporting services for hospitalized patients is challenging when multiple services for the same patient are provided on the same date by the same or different physician, also known as concurrent care. Each physician manages a particular aspect while still considering the patient’s overall condition; each physician should report the corresponding diagnosis for that management. If billed correctly, each physician will have a different primary diagnosis code to justify their involvement, increasing their opportunity for payment.³

The non-primary diagnoses might also be listed on the claim if appropriately addressed in the documentation (i.e. “non-primary” conditions’ indirect role in the focused management of the primary condition). For example, a hospitalist, pulmonologist, and nephrologist manage a patient’s uncontrolled diabetes (250.02), COPD exacerbation (491.21), and CRI (585.9), respectively. Each may report subsequent hospital care (99231-99233) for medically necessary concurrent care:

• Hospitalist: 250.02, 491.21, 585.9;
• Pulmonologist: 491.21, 250.02, 585.9; and
• Nephrologist: 585.9, 492.21, 250.02.

Coverage Determinations

Code comparisons can be made after diagnosis code selection. Coverage determinations identify specific conditions (i.e. ICD-9-CM codes) for which services are considered medically necessary. They also outline the frequency interval at which services can be performed, when applicable.

For example, vascular studies (e.g. CPT 93971) are indicated for the preoperative examination (ICD-9-CM V72.83) of potential harvest vein grafts prior to bypass surgery.⁴ This is a covered service only when the results of the study are necessary to locate suitable graft vessels. The need for bypass surgery must be determined prior to performance of the test. V72.83 is “covered” only when reported for a unilateral study, not a bilateral study (CPT 93970). Frequency parameters allow for only one preoperative scan.⁴

Coverage determination can occur on two levels: national and local. The Centers for Medicare & Medicaid Services (CMS) develops national coverage determinations (NCDs) through an evidence-based process, with opportunities for public participation.⁵ All Medicare administrative contractors must abide by NCDs without imposing further limitations or guidelines. As example, the NCD “Consultations With a Beneficiary’s Family and Associates” permits a physician to provide counseling to family members. Family counseling services are covered only when the primary purpose of such counseling is the treatment of the patient’s condition.⁶

Non-Medicare payors do not have to follow federal guidelines unless the member participates in a Medicare managed-care plan.

In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD).⁵ LCDs vary by state, creating an inconsistent approach to medical coverage. The vascular study guidelines listed above do not apply to all contractors. For example, Trailblazer Health Enterprises’ policy does not reference preoperative exams being limited to unilateral studies.⁷ (A listing of Medicare Contractor LCDs can be found at www.cms.hhs.gov/DeterminationProcess/04_LCDs.asp.)

Other Considerations

Investigate “medical necessity” denials. Do not take them at face value. Billing personnel often assume that the physician reported an incorrect diagnosis code. Consider the service when trying to formulate a response to the denial. Procedures (surgical or diagnostic services) may be denied for an invalid diagnosis. After reviewing the documentation to ensure that it supports the diagnosis, the claim may be resubmitted with a corrected diagnosis code, when applicable. Denials for frequency limitations can only be appealed with documentation that explicitly identifies the need for the service beyond the contractor-stated parameters.

If the “medical necessity” denial involves a covered evaluation and management (E/M) visit, it is less likely to be diagnosis-related. More likely, when dealing with Medicare contractors, the denial is the result of a failed response to a prepayment request for documentation. Medicare typically issues a request to review documentation prior to payment for the following inpatient E/M services: 99223, 99233, 99239, and 99292.

If the documentation is not provided to the Medicare prepayment review department within the designated time frame, the claim is automatically denied with a citation of “not deemed a medical necessity.” Acknowledge this remittance remark and do not assume that the physician assigned an incorrect diagnosis code. Although this is a possibility, it is more likely due to the failed request response. Appealing these claims requires submission of documentation to the Medicare appeals department. Reimbursement is provided once supportive documentation is received.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Social Security Administration. Exclusions from coverage and Medicare as a secondary payer. Social Security Administration website. Available at: http://www.ssa.gov/OP_Home/ssact/title18/1862.htm. Accessed March 1, 2012.
2. Highmark Medicare Services. A/B Reference Manual: Chapter 6, Medical Coverage, Medical Necessity, and Medical Policy. Highmark Medicare Services website. Available at: http://www.highmarkmedicareservices.com/refman/chapter-6.html. Accessed March 1, 2012.
3. Pohlig C. Daily care conundrums. The Hospitalist. 2008;12(12):18.
4. Highmark Medicare Services. LCD L27506: Non-Invasive Peripheral Venous Studies. Highmark Medicare Services website. Available at: http://www.highmarkmedicareservices.com/policy/mac-ab/l27506-r10.html. Accessed March 1, 2012.
5. Centers for Medicare & Medicaid Services. Medicare Coverage Determination Process: Overview. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.hhs.gov/DeterminationProcess/01_Overview.asp#TopOfPage. Accessed March 1, 2012.
6. Centers for Medicare & Medicaid Services. Medicare National Coverage Determination Manual: Chapter 1, Part 1, Section 70.1. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf. Accessed March 1, 2012.
7. Trailblazer Health Enterprises. LCD 2866: Non-Invasive Venous Studies. Trailblazer Health Enterprises website. Available at: http://www.trailblazerhealth.com/Tools/LCDs.aspx?ID=2866. Accessed March 1, 2012.

Under Section 1862(a)(1)(A) of the Social Security Act, the Medicare program may only pay for items and services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,” unless there is another statutory authorization for payment (e.g. colorectal cancer screening).¹ Coverage limitations include:²

• Proven clinical efficacy. For example, Medicare deems acupuncture “experimental/investigational” in the diagnosis or treatment of illness or injury;
• Diagnoses. As an example, vitamin B-12 injections are covered, but only for such diagnoses as pernicious anemia and dementias secondary to vitamin B-12 deficiency; and
• Frequency/utilization parameters. For example, a screening colonoscopy (G0105) can be paid once every 24 months for beneficiaries who are at high risk for colorectal cancer; otherwise the service is limited to once every 10 years.

Beyond these factors, individual consideration might be granted. Supportive and unambiguous documentation (medical records, clinical studies, etc.) must be submitted when the clinical circumstances do not appear to support the medical necessity for the service.

Diagnoses Selection

Select the code that best represents the primary reason for the service or procedure on a given date. In the absence of a definitive diagnosis, the code may correspond to a sign or symptom. Physicians never should report a code that represents a probable, suspected, or “rule out” condition. Although facility billing might consider these unconfirmed circumstances (when necessary), physician billing prohibits this practice.

Reporting services for hospitalized patients is challenging when multiple services for the same patient are provided on the same date by the same or different physician, also known as concurrent care. Each physician manages a particular aspect while still considering the patient’s overall condition; each physician should report the corresponding diagnosis for that management. If billed correctly, each physician will have a different primary diagnosis code to justify their involvement, increasing their opportunity for payment.³

The non-primary diagnoses might also be listed on the claim if appropriately addressed in the documentation (i.e. “non-primary” conditions’ indirect role in the focused management of the primary condition). For example, a hospitalist, pulmonologist, and nephrologist manage a patient’s uncontrolled diabetes (250.02), COPD exacerbation (491.21), and CRI (585.9), respectively. Each may report subsequent hospital care (99231-99233) for medically necessary concurrent care:

• Hospitalist: 250.02, 491.21, 585.9;
• Pulmonologist: 491.21, 250.02, 585.9; and
• Nephrologist: 585.9, 492.21, 250.02.

Coverage Determinations

Code comparisons can be made after diagnosis code selection. Coverage determinations identify specific conditions (i.e. ICD-9-CM codes) for which services are considered medically necessary. They also outline the frequency interval at which services can be performed, when applicable.

For example, vascular studies (e.g. CPT 93971) are indicated for the preoperative examination (ICD-9-CM V72.83) of potential harvest vein grafts prior to bypass surgery.⁴ This is a covered service only when the results of the study are necessary to locate suitable graft vessels. The need for bypass surgery must be determined prior to performance of the test. V72.83 is “covered” only when reported for a unilateral study, not a bilateral study (CPT 93970). Frequency parameters allow for only one preoperative scan.⁴

Coverage determination can occur on two levels: national and local. The Centers for Medicare & Medicaid Services (CMS) develops national coverage determinations (NCDs) through an evidence-based process, with opportunities for public participation.⁵ All Medicare administrative contractors must abide by NCDs without imposing further limitations or guidelines. As example, the NCD “Consultations With a Beneficiary’s Family and Associates” permits a physician to provide counseling to family members. Family counseling services are covered only when the primary purpose of such counseling is the treatment of the patient’s condition.⁶

Non-Medicare payors do not have to follow federal guidelines unless the member participates in a Medicare managed-care plan.

In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD).⁵ LCDs vary by state, creating an inconsistent approach to medical coverage. The vascular study guidelines listed above do not apply to all contractors. For example, Trailblazer Health Enterprises’ policy does not reference preoperative exams being limited to unilateral studies.⁷ (A listing of Medicare Contractor LCDs can be found at www.cms.hhs.gov/DeterminationProcess/04_LCDs.asp.)

Other Considerations

Investigate “medical necessity” denials. Do not take them at face value. Billing personnel often assume that the physician reported an incorrect diagnosis code. Consider the service when trying to formulate a response to the denial. Procedures (surgical or diagnostic services) may be denied for an invalid diagnosis. After reviewing the documentation to ensure that it supports the diagnosis, the claim may be resubmitted with a corrected diagnosis code, when applicable. Denials for frequency limitations can only be appealed with documentation that explicitly identifies the need for the service beyond the contractor-stated parameters.

If the “medical necessity” denial involves a covered evaluation and management (E/M) visit, it is less likely to be diagnosis-related. More likely, when dealing with Medicare contractors, the denial is the result of a failed response to a prepayment request for documentation. Medicare typically issues a request to review documentation prior to payment for the following inpatient E/M services: 99223, 99233, 99239, and 99292.

If the documentation is not provided to the Medicare prepayment review department within the designated time frame, the claim is automatically denied with a citation of “not deemed a medical necessity.” Acknowledge this remittance remark and do not assume that the physician assigned an incorrect diagnosis code. Although this is a possibility, it is more likely due to the failed request response. Appealing these claims requires submission of documentation to the Medicare appeals department. Reimbursement is provided once supportive documentation is received.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Social Security Administration. Exclusions from coverage and Medicare as a secondary payer. Social Security Administration website. Available at: http://www.ssa.gov/OP_Home/ssact/title18/1862.htm. Accessed March 1, 2012.
2. Highmark Medicare Services. A/B Reference Manual: Chapter 6, Medical Coverage, Medical Necessity, and Medical Policy. Highmark Medicare Services website. Available at: http://www.highmarkmedicareservices.com/refman/chapter-6.html. Accessed March 1, 2012.
3. Pohlig C. Daily care conundrums. The Hospitalist. 2008;12(12):18.
4. Highmark Medicare Services. LCD L27506: Non-Invasive Peripheral Venous Studies. Highmark Medicare Services website. Available at: http://www.highmarkmedicareservices.com/policy/mac-ab/l27506-r10.html. Accessed March 1, 2012.
5. Centers for Medicare & Medicaid Services. Medicare Coverage Determination Process: Overview. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.hhs.gov/DeterminationProcess/01_Overview.asp#TopOfPage. Accessed March 1, 2012.
6. Centers for Medicare & Medicaid Services. Medicare National Coverage Determination Manual: Chapter 1, Part 1, Section 70.1. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf. Accessed March 1, 2012.
7. Trailblazer Health Enterprises. LCD 2866: Non-Invasive Venous Studies. Trailblazer Health Enterprises website. Available at: http://www.trailblazerhealth.com/Tools/LCDs.aspx?ID=2866. Accessed March 1, 2012.

Under Section 1862(a)(1)(A) of the Social Security Act, the Medicare program may only pay for items and services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,” unless there is another statutory authorization for payment (e.g. colorectal cancer screening).¹ Coverage limitations include:²

• Proven clinical efficacy. For example, Medicare deems acupuncture “experimental/investigational” in the diagnosis or treatment of illness or injury;
• Diagnoses. As an example, vitamin B-12 injections are covered, but only for such diagnoses as pernicious anemia and dementias secondary to vitamin B-12 deficiency; and
• Frequency/utilization parameters. For example, a screening colonoscopy (G0105) can be paid once every 24 months for beneficiaries who are at high risk for colorectal cancer; otherwise the service is limited to once every 10 years.

Beyond these factors, individual consideration might be granted. Supportive and unambiguous documentation (medical records, clinical studies, etc.) must be submitted when the clinical circumstances do not appear to support the medical necessity for the service.

Diagnoses Selection

Select the code that best represents the primary reason for the service or procedure on a given date. In the absence of a definitive diagnosis, the code may correspond to a sign or symptom. Physicians never should report a code that represents a probable, suspected, or “rule out” condition. Although facility billing might consider these unconfirmed circumstances (when necessary), physician billing prohibits this practice.

Reporting services for hospitalized patients is challenging when multiple services for the same patient are provided on the same date by the same or different physician, also known as concurrent care. Each physician manages a particular aspect while still considering the patient’s overall condition; each physician should report the corresponding diagnosis for that management. If billed correctly, each physician will have a different primary diagnosis code to justify their involvement, increasing their opportunity for payment.³

The non-primary diagnoses might also be listed on the claim if appropriately addressed in the documentation (i.e. “non-primary” conditions’ indirect role in the focused management of the primary condition). For example, a hospitalist, pulmonologist, and nephrologist manage a patient’s uncontrolled diabetes (250.02), COPD exacerbation (491.21), and CRI (585.9), respectively. Each may report subsequent hospital care (99231-99233) for medically necessary concurrent care:

• Hospitalist: 250.02, 491.21, 585.9;
• Pulmonologist: 491.21, 250.02, 585.9; and
• Nephrologist: 585.9, 492.21, 250.02.

Coverage Determinations

Code comparisons can be made after diagnosis code selection. Coverage determinations identify specific conditions (i.e. ICD-9-CM codes) for which services are considered medically necessary. They also outline the frequency interval at which services can be performed, when applicable.

For example, vascular studies (e.g. CPT 93971) are indicated for the preoperative examination (ICD-9-CM V72.83) of potential harvest vein grafts prior to bypass surgery.⁴ This is a covered service only when the results of the study are necessary to locate suitable graft vessels. The need for bypass surgery must be determined prior to performance of the test. V72.83 is “covered” only when reported for a unilateral study, not a bilateral study (CPT 93970). Frequency parameters allow for only one preoperative scan.⁴

Coverage determination can occur on two levels: national and local. The Centers for Medicare & Medicaid Services (CMS) develops national coverage determinations (NCDs) through an evidence-based process, with opportunities for public participation.⁵ All Medicare administrative contractors must abide by NCDs without imposing further limitations or guidelines. As example, the NCD “Consultations With a Beneficiary’s Family and Associates” permits a physician to provide counseling to family members. Family counseling services are covered only when the primary purpose of such counseling is the treatment of the patient’s condition.⁶

Non-Medicare payors do not have to follow federal guidelines unless the member participates in a Medicare managed-care plan.

In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD).⁵ LCDs vary by state, creating an inconsistent approach to medical coverage. The vascular study guidelines listed above do not apply to all contractors. For example, Trailblazer Health Enterprises’ policy does not reference preoperative exams being limited to unilateral studies.⁷ (A listing of Medicare Contractor LCDs can be found at www.cms.hhs.gov/DeterminationProcess/04_LCDs.asp.)

Other Considerations

Investigate “medical necessity” denials. Do not take them at face value. Billing personnel often assume that the physician reported an incorrect diagnosis code. Consider the service when trying to formulate a response to the denial. Procedures (surgical or diagnostic services) may be denied for an invalid diagnosis. After reviewing the documentation to ensure that it supports the diagnosis, the claim may be resubmitted with a corrected diagnosis code, when applicable. Denials for frequency limitations can only be appealed with documentation that explicitly identifies the need for the service beyond the contractor-stated parameters.

If the “medical necessity” denial involves a covered evaluation and management (E/M) visit, it is less likely to be diagnosis-related. More likely, when dealing with Medicare contractors, the denial is the result of a failed response to a prepayment request for documentation. Medicare typically issues a request to review documentation prior to payment for the following inpatient E/M services: 99223, 99233, 99239, and 99292.

If the documentation is not provided to the Medicare prepayment review department within the designated time frame, the claim is automatically denied with a citation of “not deemed a medical necessity.” Acknowledge this remittance remark and do not assume that the physician assigned an incorrect diagnosis code. Although this is a possibility, it is more likely due to the failed request response. Appealing these claims requires submission of documentation to the Medicare appeals department. Reimbursement is provided once supportive documentation is received.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Social Security Administration. Exclusions from coverage and Medicare as a secondary payer. Social Security Administration website. Available at: http://www.ssa.gov/OP_Home/ssact/title18/1862.htm. Accessed March 1, 2012.
2. Highmark Medicare Services. A/B Reference Manual: Chapter 6, Medical Coverage, Medical Necessity, and Medical Policy. Highmark Medicare Services website. Available at: http://www.highmarkmedicareservices.com/refman/chapter-6.html. Accessed March 1, 2012.
3. Pohlig C. Daily care conundrums. The Hospitalist. 2008;12(12):18.
4. Highmark Medicare Services. LCD L27506: Non-Invasive Peripheral Venous Studies. Highmark Medicare Services website. Available at: http://www.highmarkmedicareservices.com/policy/mac-ab/l27506-r10.html. Accessed March 1, 2012.
5. Centers for Medicare & Medicaid Services. Medicare Coverage Determination Process: Overview. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.hhs.gov/DeterminationProcess/01_Overview.asp#TopOfPage. Accessed March 1, 2012.
6. Centers for Medicare & Medicaid Services. Medicare National Coverage Determination Manual: Chapter 1, Part 1, Section 70.1. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf. Accessed March 1, 2012.
7. Trailblazer Health Enterprises. LCD 2866: Non-Invasive Venous Studies. Trailblazer Health Enterprises website. Available at: http://www.trailblazerhealth.com/Tools/LCDs.aspx?ID=2866. Accessed March 1, 2012.

According to a CMS statement regarding part of President Obama’s “commitment to reducing regulatory burden,” Health and Human Services Secretary Kathleen G. Sebelius announced that HHS will initiate a process to “postpone the date” by which certain healthcare entities have to comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).¹

The final rule adopting ICD-10 as a standard was published in January 2009; it set a compliance date of Oct. 1, 2013 (a two-year delay from the 2008 proposed rule). HHS will announce a new compliance date moving forward.

“ICD-10 codes are important to many positive improvements in our healthcare system,” Sebelius said in the statement. “We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead. We are committing to work with the provider community to re-examine the pace at which HHS and the nation implement these important improvements to our healthcare system.”

ICD-10 codes provide more robust and specific data that will help improve patient care and enable the exchange of our healthcare data with that of the rest of the world, much of which has long been using ICD-10. Entities covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will be required to use the ICD-10 diagnostic and procedure codes.

All that said, do not postpone any activities toward ICD-10 implementation until further clarification comes from CMS.

—Carol Pohlig

Reference

1. Centers for Medicare & Medicaid Services. Press Releases: HHS Announces Intent to Delay ICD-10 Compliance Date. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/apps/media/press/release.asp?Counter=4274&intNumPerPage=30&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=false&cboOrder=date. Accessed March 1, 2012.

According to a CMS statement regarding part of President Obama’s “commitment to reducing regulatory burden,” Health and Human Services Secretary Kathleen G. Sebelius announced that HHS will initiate a process to “postpone the date” by which certain healthcare entities have to comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).¹

The final rule adopting ICD-10 as a standard was published in January 2009; it set a compliance date of Oct. 1, 2013 (a two-year delay from the 2008 proposed rule). HHS will announce a new compliance date moving forward.

“ICD-10 codes are important to many positive improvements in our healthcare system,” Sebelius said in the statement. “We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead. We are committing to work with the provider community to re-examine the pace at which HHS and the nation implement these important improvements to our healthcare system.”

ICD-10 codes provide more robust and specific data that will help improve patient care and enable the exchange of our healthcare data with that of the rest of the world, much of which has long been using ICD-10. Entities covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will be required to use the ICD-10 diagnostic and procedure codes.

All that said, do not postpone any activities toward ICD-10 implementation until further clarification comes from CMS.

—Carol Pohlig

Reference

1. Centers for Medicare & Medicaid Services. Press Releases: HHS Announces Intent to Delay ICD-10 Compliance Date. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/apps/media/press/release.asp?Counter=4274&intNumPerPage=30&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=false&cboOrder=date. Accessed March 1, 2012.

According to a CMS statement regarding part of President Obama’s “commitment to reducing regulatory burden,” Health and Human Services Secretary Kathleen G. Sebelius announced that HHS will initiate a process to “postpone the date” by which certain healthcare entities have to comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).¹

The final rule adopting ICD-10 as a standard was published in January 2009; it set a compliance date of Oct. 1, 2013 (a two-year delay from the 2008 proposed rule). HHS will announce a new compliance date moving forward.

“ICD-10 codes are important to many positive improvements in our healthcare system,” Sebelius said in the statement. “We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead. We are committing to work with the provider community to re-examine the pace at which HHS and the nation implement these important improvements to our healthcare system.”

ICD-10 codes provide more robust and specific data that will help improve patient care and enable the exchange of our healthcare data with that of the rest of the world, much of which has long been using ICD-10. Entities covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will be required to use the ICD-10 diagnostic and procedure codes.

All that said, do not postpone any activities toward ICD-10 implementation until further clarification comes from CMS.

—Carol Pohlig

Reference

1. Centers for Medicare & Medicaid Services. Press Releases: HHS Announces Intent to Delay ICD-10 Compliance Date. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/apps/media/press/release.asp?Counter=4274&intNumPerPage=30&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=false&cboOrder=date. Accessed March 1, 2012.